Bethany G. Everett

Social, Behavioral, and Biological Factors, and Sex Differences in Mortality

Few studies have examined whether sex differences in mortality are associated with different distributions of risk factors or result from the unique relationships between risk factors and mortality for men and women. We extend previous research by systematically testing a variety of factors, including health behaviors, social ties, socioeconomic status, and biological indicators of health. We employ the National Health and Nutritional Examination Survey III Linked Mortality File and use Cox proportional hazards models to examine sex differences in adult mortality in the United States. Our findings document that social and behavioral characteristics are key factors related to the sex gap in mortality. Once we control for women’s lower levels of marriage, poverty, and exercise, the sex gap in mortality widens; and once we control for women’s greater propensity to visit with friends and relatives, attend religious services, and abstain from smoking, the sex gap in mortality narrows. Biological factors—including indicators of inflammation and cardiovascular risk—also inform sex differences in mortality. Nevertheless, persistent sex differences in mortality remain: compared with women, men have 30% to 83% higher risks of death over the follow-up period, depending on the covariates included in the model. Although the prevalence ofriskfactors differs by sex, the impact of those riskfactors on mortality is similar for men and women.

Sexual Orientation Disparities in Sexually Transmitted Infections: Examining the Intersection Between Sexual Identity and Sexual Behavior

The terms MSM (men who have sex with men) and WSW (women who have sex with women) have been used with increasing frequency in the public health literature to examine sexual orientation disparities in sexual health. These categories, however, do not allow researchers to examine potential differences in sexually transmitted infection (STI) risk by sexual orientation identity. Using data from the National Longitudinal Survey of Adolescent Health, this study investigated the relationship between self-reported STIs and both sexual orientation identity and sexual behaviors. Additionally, this study examined the mediating role of victimization and STI risk behaviors on the relationship between sexual orientation and self-reported STIs. STI risk was found to be elevated among heterosexual-WSW and bisexual women, whether they reported same-sex partners or not, whereas gay-identified WSW were less likely to report an STI compared to heterosexual women with opposite sex relationships only. Among males, heterosexual-identified MSM did not have a greater likelihood of reporting an STI diagnosis; rather, STI risk was concentrated among gay and bisexual identified men who reported both male and female sexual partners. STI risk behaviors mediated the STI disparities among both males and females, and victimization partially mediated STI disparities among female participants. These results suggest that relying solely on behavior-based categories, such as MSM and WSW, may mischaracterize STI disparities by sexual orientation.

Eating disorder symptoms and obesity at the intersections of gender, ethnicity, and sexual orientation in US high school students.

OBJECTIVES We examined purging for weight control, diet pill use, and obesity across sexual orientation identity and ethnicity groups. METHODS Anonymous survey data were analyzed from 24 591 high school students of diverse ethnicities in the federal Youth Risk Behavioral Surveillance System Survey in 2005 and 2007. Self-reported data were gathered on gender, ethnicity, sexual orientation identity, height, weight, and purging and diet pill use in the past 30 days. We used multivariable logistic regression to estimate odds of purging, diet pill use, and obesity associated with sexual orientation identity in gender-stratified models and examined for the presence of interactions between ethnicity and sexual orientation. RESULTS Lesbian, gay, and bisexual (LGB) identity was associated with substantially elevated odds of purging and diet pill use in both girls and boys (odds ratios [OR] range = 1.9-6.8). Bisexual girls and boys were also at elevated odds of obesity compared to same-gender heterosexuals (OR = 2.3 and 2.1, respectively). CONCLUSIONS Interventions to reduce eating disorders and obesity that are appropriate for LGB youths of diverse ethnicities are urgently needed.

Sexual Orientation Disparities in Cancer-Related Risk Behaviors of Tobacco, Alcohol, Sexual Behaviors, and Diet and Physical Activity: Pooled Youth Risk Behavior Surveys

OBJECTIVES We examined sexual orientation disparities in cancer-related risk behaviors among adolescents. METHODS We pooled data from the 2005 and 2007 Youth Risk Behavior Surveys. We classified youths with any same-sex orientation as sexual minority and the remainder as heterosexual. We compared the groups on risk behaviors and stratified by gender, age (< 15 years and > 14 years), and race/ethnicity. RESULTS Sexual minorities (7.6% of the sample) reported more risk behaviors than heterosexuals for all 12 behaviors (mean = 5.3 vs 3.8; P < .001) and for each risk behavior: odds ratios (ORs) ranged from 1.3 (95% confidence interval [CI] = 1.2, 1.4) to 4.0 (95% CI = 3.6, 4.7), except for a diet low in fruit and vegetables (OR = 0.7; 95% CI = 0.5, 0.8). We found sexual orientation disparities in analyses by gender, followed by age, and then race/ethnicity; they persisted in analyses by gender, age, and race/ethnicity, although findings were nuanced. CONCLUSIONS Data on cancer risk, morbidity, and mortality by sexual orientation are needed to track the potential but unknown burden of cancer among sexual minorities.

The Association Between Sexual Orientation Identity and Behavior Across Race/Ethnicity, Sex, and Age in a Probability Sample of High School Students

OBJECTIVES We examined the prevalence and associations between behavioral and identity dimensions of sexual orientation among adolescents in the United States, with consideration of differences associated with race/ethnicity, sex, and age. METHODS We used pooled data from 2005 and 2007 Youth Risk Behavior Surveys to estimate prevalence of sexual orientation variables within demographic sub-groups. We used multilevel logistic regression models to test differences in the association between sexual orientation identity and sexual behavior across groups. RESULTS There was substantial incongruence between behavioral and identity dimensions of sexual orientation, which varied across sex and race/ethnicity. Whereas girls were more likely to identify as bisexual, boys showed a stronger association between same-sex behavior and a bisexual identity. The pattern of association of age with sexual orientation differed between boys and girls. CONCLUSIONS Our results highlight demographic differences between 2 sexual orientation dimensions, and their congruence, among 13- to 18-year-old adolescents. Future research is needed to better understand the implications of such differences, particularly in the realm of health and health disparities.

Indicators of Victimization and Sexual Orientation Among Adolescents: Analyses From Youth Risk Behavior Surveys

OBJECTIVES We used nuanced measures of sexual minority status to examine disparities in victimization and their variations by gender, age, and race/ethnicity. METHODS We conducted multivariate analyses of pooled data from the 2005 and 2007 Youth Risk Behavior Surveys. RESULTS Although all sexual minorities reported more fighting, skipping school because they felt unsafe, and having property stolen or damaged at school than did heterosexuals, rates were highest among youths who identified as bisexual or who reported both male and female sexual partners. Gender differences among sexual minorities appeared to be concentrated among bisexuals and respondents who reported sexual partners of both genders. Sexual minority youths reported more fighting than heterosexual youths, especially at younger ages, and more nonphysical school victimization that persisted through adolescence. White and Hispanic sexual minority youths reported more indicators of victimization than did heterosexuals; we found few sexual minority differences among African American and Asian American youths. CONCLUSIONS Victimization carries health consequences, and sexual minorities are at increased risk. Surveys should include measures that allow tracking of disparities in victimization by sexual minority status.

The Nonlinear Relationship Between Education and Mortality: An Examination of Cohort, Race/Ethnic, and Gender Differences

Researchers investigating the relationship between education and mortality in industrialized countries have consistently shown that higher levels of education are associated with decreased mortality risk. The shape of the education–mortality relationship and how it varies by demographic group have been examined less frequently. Using the U.S. National Health Interview Survey-Linked Mortality Files, which link the 1986 through 2004 NHIS to the National Death Index through 2006, we examine the shape of the education–mortality curve by cohort, race/ethnicity, and gender. Whereas traditional regression models assume a constrained functional form for the dependence of education and mortality, in most cases semiparametric models allow us to more accurately describe how the association varies by cohort, both between and within race/ethnic and gender subpopulations. Notably, we find significant changes over time in both the shape and the magnitude of the education–mortality gradient across cohorts of women and white men, but little change among younger cohorts of black men. Such insights into demographic patterns in education and mortality can ultimately help increase life expectancies.

Educational Degrees and Adult Mortality Risk in the United States

We present the first published estimates of U. S. adult mortality risk by detailed educational degree, including advanced postsecondary degrees. We use the 1997–2002 National Health Interview Survey (NHIS) Linked Mortality Files and Cox proportional hazards models to reveal wide graded differences in mortality by educational degree. Compared to adults who have a professional degree, those with an MA are 5 percent, those with a BA are 26 percent, those with an AA are 44 percent, those with some college are 65 percent, high school graduates are 80 percent, and those with a GED or 12 or fewer years of schooling are at least 95 percent more likely to die during the follow-up period, net of sociodemographic controls. These differentials vary by gender and cohort. Advanced educational degrees are associated not only with increased workforce skill level but with a reduced risk of death.

The Effects of Children’s Migration on Elderly Kin’s Health: A Counterfactual Approach

Recent studies of migration and the left-behind have found that elders with migrant children actually experience better health outcomes than those with no migrant children, yet these studies raise many concerns about self-selection. Using three rounds of panel survey data from the Indonesian Family Life Survey, we employ the counterfactual framework developed by Rosenbaum and Rubin to examine the relationship between having a migrant child and the health of elders aged 50 and older, as measured by activities of daily living (ADL), self-rated health (SRH), and mortality. As in earlier studies, we find a positive association between old-age health and children’s migration, an effect that is partly explained by an individual’s propensity to have migrant children. Positive impacts of migration are much greater among elders with a high propensity to have migrant children than among those with low propensity. We note that migration is one of the single greatest sources of health disparity among the elders in our study population, and point to the need for research and policy aimed at broadening the benefits of migration to better improve health systems rather than individual health.

Lifetime Victimization, Hazardous Drinking, and Depression Among Heterosexual and Sexual Minority Women

PURPOSE Substantial research documents sexual-orientation-related mental health disparities, but relatively few studies have explored underlying causes of these disparities. The goals of this article were to (1) understand how differences in sexual identity and victimization experiences influence risk of hazardous drinking and depression, and (2) describe variations across sexual minority subgroups. METHODS We pooled data from the 2001 National Study of Health and Life Experiences of Women and the 2001 Chicago Health and Life Experiences of Women study to compare rates of victimization, hazardous drinking, and depression between heterosexual women and sexual minority women (SMW), and to test the relationship between the number of victimization experiences and the study outcomes in each of five sexual identity subgroups. RESULTS Rates of each of the major study variables varied substantially by sexual identity, with bisexual and mostly heterosexual women showing significantly higher risk than heterosexual women on one or both of the study outcomes. The number of victimization experiences explained some, but not all, of the risk of hazardous drinking and depression among SMW. CONCLUSION Although victimization plays an important role, sexual-minority-specific stressors, such as stigma and discrimination, likely also help explain substance use and mental health disparities among SMW.